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Effect of smoking cessation intervention on results of acute fracture surgery: a randomized controlled trial. J Bone Joint Surg Am. 2010 Jun;92(6):1335-42.

Abstract Nyckelord: akut operation, kvalificerad behandling, rökfri operation, ortopedi, komplikationer.

BACKGROUND: Tobacco smoking is a major health and economic concern and is also known to have a significant negative effect on surgical outcomes. The benefits of a smoking cessation intervention prior to elective orthopaedic surgery have been evaluated previously. Our aim was to assess whether a smoking cessation program, initiated during the acute hospitalization period and carried out for six weeks, could reduce the number of complications following emergency surgical treatment of fractures.

METHODS: In a multicenter, single-blinded, randomized, controlled clinical trial, 105 smokers with a fracture of the lower or upper extremity that needed acute surgical treatment were randomized to an intervention group (n = 50) or a control group (n = 55). The intervention group was offered a standardized smoking cessation program for six weeks, and all patients were followed at two to three weeks, four weeks, and six to twelve weeks.

RESULTS: The proportion of patients with at least one postoperative complication was significantly larger in the control group than it was in the intervention group (38% and 20%, respectively; p = 0.048). The development of two or more postoperative complications was also more common among the controls (p = 0.039). The rates of superficial wound infection, the most frequently recorded complication in both groups, were 20% and 8%, but this difference was not significant. A secondary analysis showed that the odds of having a complication were 2.51 times (95% confidence interval, 0.96 to 6.9 times) higher in the control group than in the intervention group, but this difference was not significant.

CONCLUSIONS: Our results indicate that a smoking cessation intervention program during the first six weeks after acute fracture surgery decreases the risk of postoperative complications.

Sadr Azodi O, Lindström D, Adami J, Tønnesen H, Nåsell H, Gilljam H, Wladis A.

The efficacy of a smoking cessation programme in patients undergoing elective surgery: a randomised clinical trial. Anaesthesia. 2009 Mar;64(3):259-65.

Department of Medicine, Clinical Epidemiology Unit, Karolinska Institute, Stockholm, Sweden. sayed-omid.sadrazodi@ki.se

Abstract Nyckelord: elektiv operation, kvalificerad behandling, rökfri operation, rökfrihet.

It is known that smokers constitute an important risk group of patients undergoing surgery. It is unknown how smoking cessation intervention initiated 4 weeks prior to elective surgery affects the probability of permanent cessation. We randomly assigned 117 patients, scheduled to undergo elective orthopaedic and general surgery, to smoking cessation intervention and control group. The intervention group underwent a programme initiated, on average, 4 weeks prior to surgery with weekly meetings or telephone counselling and were provided with free nicotine replacement therapy (NRT). The control group received standard care. As a result, 20/55 (36%) patients the intervention group vs 1/62 (2%) in the control group became completely abstinent throughout the peri-operative period (p < 0.001). After 1 year, those in the intervention group was most likely to be abstinent (18/55 (33%) vs 9/62 (15%) of the controls (p = 0.03). Level of nicotine dependence and obesity seemed to be a predictor of long-term abstinence (p = 0.02).

Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J.

Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008 Nov;248(5):739-45.

Surgery Section, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden. David.lindstrom@ki.se

Abstract Nyckelord: elektiv operation, rökfri operation, kvalificerad behandling, ortopedi, allmän kirurgi, komplikationer.

OBJECTIVE: To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications.

SUMMARY BACKGROUND DATA: Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications.
METHODS: A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled.

INTERVENTION: Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication.

RESULTS: An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3-40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant.

CONCLUSION: Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

Lindström D, Sundberg-Petersson I, Adami J, Tönnesen H.

Disappointment and drop-out rate after being allocated to control group in a smoking cessation trial. Contemp Clin Trials. 2010 Jan;31(1):22-6. Epub 2009 Sep 14.

Department of Clinical Science and Education, Karolinska Institute, Section of Surgery, Södersjukhuset, SE-11883 Stockholm, Sweden. David.lindstrom@ki.se

Abstract Nyckelord: elektiv operation, rökfri operation, kvalificerad behandling, rökfrihet, kontrollgrupp.

BACKGROUND: If a patient agrees to take part in a randomised trial it is reasonable to presume that the patient would prefer to be allocated into the intervention. This study's aim was to investigate how patients react after they have been randomised into control group.

METHODS: Nested study within two randomised trials. Telephone interviews with a structured questionnaire. The participants were invited after they had been randomised into the control group in two smoking cessation trials. The main outcome measures were reaction to control group allocation and drop-out rates.

RESULTS: Twenty-seven out of 30 possible interviews were successfully completed. Fourteen persons expressed that they were disappointed of being allocated to the control group. Five persons said that they had not understood the consent information and three of these were very disappointed. Surprisingly these three persons said that they had not expected a randomization. A woman expressed that she "felt as if I was being swindled". There were in total 9/117 (7.7%) lost to follow-up in the control group and there were 4/105 (3.8%) losses to follow-up in the intervention group (P=0.26). Active withdrawal of consent was slightly higher among the control group, five in the control group (4.3%) and no active withdrawals in the intervention group (P=0.06).

CONCLUSIONS: Disappointment was common after allocation to the control group. This is a probable explanation of the higher drop-out rate in the control group. The consent information is of highest importance since those who were very disappointed claimed they did not receive understandable information.

Andrews K, Bale P, Chu J, Cramer A, Aveyard P.

A randomized controlled trial to assess the effectiveness of a letter from a consultant surgeon in causing patients to stop smoking pre- operatively. Public Health 2006;120(4):356-8.

(Hela artikeln – ej abstract) Nyckelord: elektiv operation, kvalificerad behandling, rökfrihet.

People who smoke throughout life reduce their life expectancy by an average of 10 years. In addition to loss of life, smoking causes avoidable illness including morbidity from postoperative complications. Smokers are more likely to suffer from respiratory, cardiovascular and infectious complications than non-smokers when they undergo elective surgery. Stopping even a few weeks prior to surgery is associated with reduced postoperative complications.3,4 This suggests that even if smokers cannot or do not want to stop permanently, stopping smoking temporarily before an elective operation may reduce postoperative complications.

One randomized trial has shown that stopping smoking pre-operatively was associated with reduced complications.4 In this trial, patients in the intervention group were seen weekly prior to their surgery for 6–8 weeks, with a personalized plan for smoking reduction or cessation together with the prescription of nicotine replacement. About one-half of the control group and one-fifth of the intervention group suffered complications; this difference was statistically significant and clinically important. This trial used a relatively intensive smoking cessation programme and, to the authors' knowledge, has not been adopted by any National Health Service (NHS) hospital.

The present article reports the results of a small randomized trial to assess the effect of simple clear advice to stop smoking from a consultant surgeon. The advice was given by letter and thus would be easily implemented in current NHS practice. The trial took place in Sandwell General Hospital Department of Surgery between January and April 2004. Permission was obtained from the local research ethics and research governance committees. Patients for elective surgery are routinely seen by a nurse about 4 weeks before surgery. The nurse collects information relevant to the operation and provides advice to the patient on the preoperative and postoperative period. All patients receive a booklet that provides brief advice on the benefits of stopping smoking permanently on long-term health, but it does not state that temporary cessation would aid postoperative recovery. The nurse asked all patients who smoked whether they would be interested in taking part in a trial and explained it briefly. If patients were interested, they were introduced to one of the researchers who explained the study in more detail and asked patients to sign a consent form. The researchers carried out randomization on the preoperative ward. Each patient agreeing to participate on the pre-operative ward that day was numbered sequentially. The corresponding numbers were put in an opaque bag and the first number drawn out was assigned to intervention status. The second number was assigned to control, and so on alternately. This is block randomization with a block size of two. The intervention consisted of a letter that was given in addition to the booklet and nurse advice received by all patients. The letter was from the patient's consultant stating that ‘stopping smoking 1 or 2 weeks before surgery has huge benefits'. These benefits were then listed, such as less time for recovery and lower chance of wound infection. Patients were given the contact details of the Sandwell Stop Smoking Service.

The outcome of this study was self-reported abstinence from smoking, defined as not smoking a single puff on the day of surgery. This was assessed by a questionnaire administered by the research team to patients on the day of their operation. Participants were reassured that the information would not be given to the surgical team. No sample size calculations were undertaken because the number of participants was constrained as this was a student project. Fifty-one patients were randomized to the intervention group and 51 were randomized to the control group. One person in the control group withdrew, so 101 (99%) patients were followed-up at the time of their operation. Eighteen (18%) of the intervention group and eight (8%) of the control group had stopped smoking by the day of the operation. Ignoring the person who declined follow-up, this gives a relative risk (RR) of smoking cessation of 2.21 [95% confidence intervals (CI) 1.06-4.60]. In smoking cessation trials, it is common practice to assume that those not followed-up are smokers.  If this is assumed, the RR is 2.25 (95%CI 1.08-4.70). Of the 18 quitters in the intervention group, six (6%) claimed to be quitting permanently, compared with four (4%) of the eight quitters in the control group. The RR for intention to quit on a long-term basis was 1.33 (95%CI 0.40-4.46).

This study suggests that a letter from a consultant surgeon motivates smokers to quit smoking temporarily by the day of the operation, which may reduce postoperative complications. It was not powered to show and did not show any difference in the intention to quit smoking permanently, and did not examine any long-term cessation outcomes or postoperative outcomes.

This study has some notable strengths and weaknesses. Being a randomized trial, one can be fairly sure that the baseline characteristics of patients were well balanced given the number randomized. However, due to practical constraints, this was not assessed. However, among community samples, there are no factors strongly predictive of quitting success, so modest imbalance of these is unlikely to seriously bias the effect estimate. Also, participants' quit status was not confirmed by testing exhaled carbon monoxide. Thus, it is possible that participants in the intervention arm felt more social pressure to declare themselves a non-smoker than participants in the control arm because their consultant had asked them to stop smoking. However, the questionnaire on the day of the operation was administered by a research team member, and participants were assured that it was for research only and the consultant would not see the questionnaire. People usually give accurate information about their smoking status unless they feel strong social pressure not to do so. In this study, it was not perceived that the participants experienced strong social pressure to lie to the researchers. A final weakness was that the length of smoking cessation was not assessed. Stopping smoking on the day of the operation was assessed, but complications of surgery are only reduced if smoking is stopped for at least a few weeks prior to surgery, although the critical period is not fully known. The intervention described in this study is easy to implement in most healthcare systems, is very cheap, and has the potential to improve the health of patients and save the NHS money through reduced length of stay and reduction of postoperative complications. This preliminary study suggests that, when presented with information about the benefits, a sizable minority of patients may take action to stop smoking temporarily. This could be combined with more extensive interventions, such as the supply of nicotine replacement prior to operation, which may help patients who are strongly addicted to nicotine to suspend their smoking temporarily. Whether such interventions lead to long-term cessation remains to be seen, but the evidence here is that only a minority of those who stopped were intending to stop forever. Effectiveness of a letter from a consultant surgeon recommending stopping smoking pre-operatively  However, even on a short-term basis, stopping smoking is beneficial pre-operatively, and this study suggests that it is easy to get a minority of patients to take this action who might not have done so otherwise.

Moller AM, Villebro N, Pedersen T, Tonnesen H.

Effect of preoperative smoking intervention on postoperative complications: A randomised clinical trial. Lancet 2002;359:114-7.

Department of Anaesthesiology, Bispebjerg University Hospital, 2400 NV, Copenhagen, Denmark. docamm@yahoo.com

Abstract Nyckelord: elektiv operation, rökfri operation, kvalificerad behandling, ortopedi, komplikationer.

BACKGROUND: Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers. Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement.

METHODS: We did a randomised trial in three hospitals in Denmark. 120 patients were randomly assigned 6-8 weeks before scheduled surgery to either the control (n=60) or smoking intervention (60) group. Smoking intervention was counselling and nicotine replacement therapy, and either smoking cessation or at least 50% smoking reduction. An assessor, who was masked to the intervention, registered the occurrence of cardiopulmonary, renal, neurological, or surgical complications and duration of hospital admittance. The main analysis was by intention to treat.

FINDINGS: Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled. Thus, 52 and 56 patients, respectively, were analysed for outcome. The overall complication rate was 18% in the smoking intervention group and 52% in controls (p=0.0003). The most significant effects of intervention were seen for wound-related complications (5% vs 31%, p=0.001), cardiovascular complications (0% vs 10%, p=0.08), and secondary surgery (4% vs 15%, p=0.07). The median length of stay was 11 days (range 7–55) in the intervention group and 13 days (8–65) in the control group.

INTERPRETATION: An effective smoking intervention programme 6-8 weeks before surgery reduces postoperative morbidity, and we recommend, on the basis of our results, this programme be adopted.

Villebro NM, Pedersen T, Moller AM, Tonnesen H.

Long-term effects of a preoperative smoking cessation programme. The Clinical Respiratory Journal 2008;2:175-82. Clin Respir J. 2008 Jul;2(3):175-82.

Quality and Education Department, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, Denmark.

Abstract Nyckelord: elektiv operation, kvalificerad behandling, rökfri operation, rökfrihet.

INTRODUCTION: Preoperative smoking intervention programmes reduce post-operative complications in smokers. Little is known about the long-term effect upon smoking cessation.

AIM: To discover long-term quit rates and the reasons behind successful cessation.

MATERIALS AND METHODS: 101 one of 120 smokers, randomised to smoking intervention or no intervention before hip and knee surgery, completed questionnaires concerning smoking after 1 year. We selected representative men and women for focus group interviews.

RESULTS: Significantly more patients from the intervention group abstained from smoking for 1 year post-operatively [13 in 60 patients (22%) vs 2 in 60 (3%), P < 0.01]. Sex (male), low nicotine dependency, non-smoking spouse and preoperative smoking intervention were related to smoking cessation. All patients gave the same reasons for smoking cessation: improved health and saving money. Follow-up for 5 years showed 17% of the controls and 8% in the intervention group (P = 0.42) had died.

CONCLUSION: The intervention group had a significantly higher quit rate 1 year after a preoperative smoking cessation programme.

Ratner PA, Johnson JL, Richardson CG, Bottorff JL, Moffat B, Mackay M, et al.

Efficacy of a smoking-cessation intervention for elective-surgical patients. Research in Nursing and Health 2004;27: 148-61.

Nursing and Health Behaviour Research Unit, School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada.

Abstract Nyckelord: elektiv operation, rökfri operation, rådgivning, ortopedi, allmän kirurgi, plastikkirurgi, urologi, oftalmologi, komplikationer

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.

Sorensen LT, Jorgensen T.

Short-term preoperative smoking cessation intervention does not affect postoperative complications in colorectal surgery: A randomised clinical trial. Colorectal Disease 2003;5:347-52.

Abstract Nyckelord: elektiv operation, rökfri operation, rådgivning, colonkirurgi, komplikationer.

BACKGROUND: Smokers have a higher risk of complicated tissue and wound healing after surgery than nonsmokers. We tested the hypothesis that short-term pre-operative cessation of smoking in colorectal surgery decreases the incidence of postoperative tissue and wound complications.

METHODS: From February 1998 to March 2001, 60 patients, who smoked daily, undergoing colorectal resection were randomly assigned 2–3 weeks before scheduled surgery to either abstinence from smoking, counselling and nicotine replacement therapy or maintenance of daily smoking habits. Postoperative tissue and wound complications necessitating surgical or medical treatment were evaluated at discharge and 30 days after surgery by blinded outcome assessment.

RESULTS: In the pre-operative period of 15 days (8–24) (median, interquartile range (IQR)), 89% of the patients in the intervention group vs. 13% in the control group abstained from smoking or reduced by more than half (P < 0.05). In the postoperative period of 11 days (10–13), the corresponding figures were 92% and 50%, respectively (P < 0.05). Postoperative tissue and wound complications occurred in 33% (9 of 27) of the patients in the intervention group compared to 27% (8 of 30) in the control group (NS). Likewise, no difference in overall postoperative complication rate was found between the groups.

CONCLUSION: Short-term cessation of smoking does not reduce the risk of complicated tissue and wound healing or other complications in colorectal surgery.

Sorensen LT, Hemmingsen U, Jorgensen T.

Strategies of smoking cessation intervention before hernia surgery – effect on perioperative smoking behaviour. Hernia 2007;11:327-33.

Abstract Nyckelord: elektiv operation, rökfri operation, rådgivning, bråckkirurgi, komplikationer.

BACKGROUND: Although it is now generally accepted that patients should be advised to quit smoking before surgery, the effect of low-intensive smoking cessation intervention, both on preoperative smoking behavior and on risk reduction, remains unclear. Our objective was to study the effect on perioperative smoking behavior and on postoperative wound infection of different types of low-intensive intervention before herniotomy.

METHODS: Between October 1998 and October 2000, 180 consecutive smokers scheduled for elective herniotomy were advised to quit smoking perioperatively and subsequently allocated randomly to three low-intensive smoking cessation groups: a standard (control) group, a telephone group, which was reminded by telephone, and an out-patient group, which was reminded by means of an out-patient talk and demonstration of nicotine replacement drugs. Spontaneous perioperative smoking behavior was recorded for 64 consecutive non-advised smokers. Postoperative wound infection was evaluated by independent assessors.

RESULTS: Of the advised patients, 19% (29/149) stopped smoking before surgery compared with 2% (1/64) in the non-advised cohort (P < 0.01). In the standard group 13% (6/48) quit smoking compared with 23% (23/101) in the pooled telephone and outpatient group (NS). In the last group 64% (65/101) reduced or stopped smoking compared with 42% (20/48) in the standard group (P < 0.05). Predictors of failed perioperative cessation of smoking were a CO breath-test at inclusion above 20 ppm (OR: 0.11; 0.02-0-57) and low motivation to quit smoking (OR: 0.25; 0.09-0.70). Wound infection occurred in 6% (13/213) and there was no difference between the groups.

CONCLUSION: Low-intensive smoking cessation intervention helps approximately one fifth of patients to stop smoking perioperatively. Patients who are reminded in addition to preoperative advice are more likely to stop or reduce smoking. Failure to stop smoking is greater if the patients are not motivated and if the CO breath test is high at the time of the preoperative advice.

Thomsen T, Esbensen BA, Samuelsen S, Tønnesen H, Møller AM.

Brief preoperative smoking cessation counselling in relation to breast cancer surgery: a qualitative study. Eur J Oncol Nurs. 2009 Dec;13(5):344-9. Epub 2009 Jun 16.

Abstract Nyckelord: elektiv operation, rökfri operation, rådgivning, bröstcancerkirurgi, patienttillfredsställelse.

AIM: To describe how women smokers with newly diagnosed breast cancer experienced brief preoperative smoking cessation intervention in relation to breast cancer surgery.

BACKGROUND: Preoperative smoking cessation intervention is relevant for short- and long-term risk reduction in newly diagnosed cancer patients. Our knowledge of how patients with malignant diagnoses experience preoperative smoking intervention is however scarce.

METHODS: A qualitative descriptive study that collected data through one-time individual, semi-structured interviews with 11 Danish women. Ricoeur's theory of interpretation was used for the analysis.

RESULTS: The women experienced that brief preoperative smoking intervention triggered reflection upon smoking and health. They furthermore experienced the smoking intervention as an opportune aid to escaping the social stigma of being a smoker. Quitting in the context of cancer diagnosis was difficult for some women. They relapsed to smoking as an ingrown response to emotional distress. The smoking intervention heightened the women's awareness of their addiction to smoking; however, they expressed a need for prolonged smoking cessation support. For others, the smoking intervention was supportive of cessation, and these women experienced smoking cessation as an enactment of a duty of responsibility to themselves and those nearest to them. They furthermore experienced a sense of personal achievement, improved well-being and endorsement from family and friends.

CONCLUSION: In newly diagnosed breast cancer patients, brief preoperative smoking intervention motivated smoking cessation. However, prolonged intervention, pre- and postoperatively, may more effectively support cessation in breast cancer patients and should therefore be evaluated in this patient population.

Wolfenden L, Wiggers J, Knight J, Campbell E, Rissel C, Kerridge R, et al.

A programme for reducing smoking in pre-operative surgical patients: randomised controlled trial. Anaesthesia 2005;60:172-9.

Abstract Nyckelord: elektiv operation, rökfri operation, kvalificerad behandling, allmän kirurgi, rökfrihet.

We assessed the efficacy of a comprehensive programme for stopping smoking in 210 smokers scheduled for surgery, before admission and 3 months after attending a pre-operative clinic. Participants were randomly allocated to receive an intervention incorporating nicotine replacement therapy for patients smoking more than 10 cigarettes per day ("dependent smokers"), or to a control group to receive usual care. Dependent smokers allocated to the intervention group were more likely to report abstinence before surgery than those allocated to receive usual-care (63 (73%) vs. 29 (56%), respectively; OR 2.2 (95% CI 1.0-4.8)), and 3 months after attendance (16 (18%) vs. 3 (5%), respectively; OR = 3.9 (95% CI 1.0-21.7).

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Göran Modins kommentarer till Debatt i SVT1

Anne i inslaget fick enligt henne själv aldrig det som idag alla rökare måste erbjudas, nämligen professionell hjälp att göra ett tillfälligt rökuppehåll inför sin operation.

Vi har i åtskilliga decennier känt till rökningens fatala effekter på hälsan. Det är dock bara under de senaste åren vi verkligen fått bevis för att rökare mycket påtagligt kan reducera riskerna i samband med en operation om de gör ett tillfälligt rökuppehåll. Risken minskar enligt många vetenskapliga studier med hälften! Vi vet dessutom hur vi idag ska kunna hjälpa patienten för att verkligen kunna lyckas med sitt tillfälliga rökuppehåll.

Varannan rökare som genomgår kirurgi utan rökuppehåll i samband med operation drabbas av någon form av komplikation! Det handlar ofta om sårläkningsproblem, sårinfektioner, lunginflammation, förlångsammad eller utebliven benläkning vid frakturer etc. etc. Det är alltså inga små och försumbara risker vi talar om.

Den nya kunskapen gör också att vi måste värdera riskerna för en rökare på ett delvis annat sätt. När vi nu känner till en riskfaktor som vi kan minska med hälften så tar vi också en medveten risk om vi inte hjälper patienten till ett tillfälligt rökupppehåll.

Vi har länge känt till riskerna med att inte normalisera ett förhöjt blodtryck eller ett oreglerat blodsocker inför en operation. Vi känner också till riskerna med att äta eller dricka straxt innan en operation. Dessa risker tycker vi idag är självklara att åtgärda innan vi utför kirurgi på en patient. Få kirurger skulle känna sig komfortabla med att operera en patient med dessa riskfaktorer utan att tillsammans med patienten först försöka åtgärda dessa risker. Att utföra kirurgi på en patient som inte vill medverka till att reducera eventuella riskfaktorer gör naturligtvis att indikationen för kirurgi i de flesta fall ändras och minskar. Sannolikt väcks också frågor om i vilken utsträckning patienten är beredd att följa andra råd och instruktioner som är nödvändiga för att nå ett lyckat behandlingsresultat.

I praktiken är patienter som inte vill medverka till att reducera sina risker inför kirurgi ett mycket litet problem. Ett väldigt mycket större problem är att det idag är väldigt många rökare som inte regelmässigt får information om möjligheterna att få professionell hjälp med ett tillfälligt rökuppehåll inför en operation och på så sätt minska sina risker med hälften. Med den övertygande kunskap vi har idag är detta verkligen något alla rökande patienter borde kräva av sin vårdgivare inför eventuell kirurgi. En rökfri operation är idag en patientsäkerhetsfråga och inte på något sätt en moraliserande livsstilsfråga. Om något är oetiskt idag så är det att inte erbjuda den hjälp som vi idag vet kan minska riskerna med kirurgi så påtagligt. Vi kan heller aldrig kräva att en kirurg ska utföra kirurgi på en patient där hon eller han gör bedömningen att riskerna är oacceptabelt höga. Både patient och läkare måste tro att möjligheterna att göra gott är tillräckligt stora.

Att inte erbjuda rökare professionell hjälp till ett tillfälligt rökstopp är diskriminerande, inte det omvända. En rökfri operation är ett nödvändigt steg mot ökad patientsäkerhet.

/Göran Modin
Ledamot i Svenska läkaresällskapets kommitté för säker vård

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Dagmar Ågren som rökt i 60 år slutade röka inför en höftledsoperation, och berättar om hur det har gått.

Se programmet på: http://www.unt.se/24unt/#category=1089620&clip=1487714&date=2011-10&startTime=0m0s